The Birth Survey is a comprehensive survey of women who have given birth within the last three years. The first of its kind, it allows women to answer questions regarding their experiences with every aspect of their maternity care from the prenatal care to the birth to perinatal and post-partum care. Examples of questions include how long of wait there was between arranging the first prenatal appointment and having it, how long of wait there was for prenatal appointments after arriving at the office, what equipment was available during labor (birth ball, birthing stool, shower, tub, etc.), and if discussions regarding post-partum mood disorders took place during post-partum care.

The Birth Survey, in addition to providing women the opportunity to review their care, allows consumers to search results and see ratings of practitioners and facilities in order to compare area options.

Semi-related, Jill at Unnecesarean has posted rates of c-section, by state, as of 2007. Current rates are likely higher.

Summary; despite the WHO's recommendation of a c-sec rate about 15%, the lowest rates for the US are about 22%.posted by emjaybee at 2:11 PM on February 15, 2010 [1 favorite]

It irks me that they don't distinguish between Certified Nurse Midwives and Direct Entry Midwives. Here's a pretty good link that explains the difference. Basically, a CNM is someone who has had formal training in nursing and midwifery. A DEM has not necessarily had this kind of training, and the requirements for certification vary by state. These are people who may or may not have any formal medical training. Yet, they are still called midwives, and it seems like few people understand the distinction.

I had all my prenatal care with a CNM, and my labor was attended largely by CNMs and nurses, until it was determined that I was going to have a Cesarean section, which was performed by an OB. I was very happy with the quality of my care. Having a CNM can have advantages over an OB, because they can usually spend more time with patients, and they are less likely to be called off for an emergency. However, I would not choose to get care from a DEM, because it seems like a crapshoot. I don't want someone with no medical training to handle my medical care, or the medical care of my unborn child.posted by lexicakes at 2:26 PM on February 15, 2010

Lexicakes, I'm pretty sure in the survey they do distinguish between CNMs and other types of midwives, and I think it's done when you select where you gave birth. Clearly, Certified Professional Midwives and/or Direct Entry Midwives (these are not necessarily the same either) would not be providing care in a hospital or a hospital affiliated birth center. But it's in very rare places that CNMs are allowed to attend births at home or in free standing birth centers --- I think Kansas might be the only state, actually, that allows licensed CNMs to attend births at home. In most other states, CNMs risk losing their licenses by doing so.

BUT, I do think if you were to have selected that you gave birth at home (had you, that is), the questions there would have been tailored differently and may even have asked about professional qualifications of the attending midwife and whether she was a CNM or a CPM or a DEM.

(And a larger number of CNMs than you might think have moved into being homebirth midwives, so there are many homebirth midwives out there who did train as nurse-midwives prior to shifting their careers into homebirth.)posted by zizzle at 2:39 PM on February 15, 2010

But no one tells you that your genitals swell. No one. And once they start, there’s nothing you can do to stop them. And it hurts
And as the baby gets heavier, it acts like a tourniquet, trapping your entire blood supply inside your labia. At some point, you may think you’ve grown giant infected testicles. Nope. Those are your girl parts.

You pooped your bed while a room full of people were staring at your bloody gaping vagina.

I have a year to go before being classified as being of an older mother and have considered the possibility of having a kid, and I'm not doing this. I just don't have it in me. Forget it. If I had any doubt, this blog post just squashed that. I am not ever, ever doing that. So help me God I am getting my tubes tied as soon as possible next possible appt. I don't care if someone thinks I'm vain or insane, I am...no, I am not doing this.

lexicakes, here in my state (TX) and many others, CPMs are licensed by the state and undergo extensive training and then a supervised apprenticeship, which requires them to have attended a given number of births, with a given number in which they are the primary midwife, much as pilots must accumulate hours.

Direct-entry or lay midwives may or may not have certification of some kind. So yes, there is a significant distinction.

The Big Push for Midwifery and the MAMA Campaign are both pushing for licensed midwifery to become part of the medical system in the US; if for example Medicare could reimburse for midwife services nationwide, then insurance companies could move them onto their rolls and then the debate over what types of certification are required and how midwives can practice will really heat up (and it's pretty heated already--turf battles between CNMs, OBs, and CPMs really complicate this issue).posted by emjaybee at 2:58 PM on February 15, 2010 [1 favorite]

What pregnant women won't tell you ever.

Pooping
You will poop during child birth. There is nothing you can do about this. Pushing is pushing.

Your doctor and husband (or other coach) will tell you that you didn’t so that you’re not too embarrassed to keep going. You’ll assume they’re being honest. You’ll brag to everyone that you didn’t. Then your husband will get drunk a year and a half later and laugh at you for dooking yourself… then laugh at you for thinking you didn’t. You’ll punch him in the balls, but it won’t change anything because he’s right. You did.

You pooped your bed while a room full of people were staring at your bloody gaping vagina.

zizzle: Thanks for the clarification. I was just noticing in the About page, that they refer to midwives generally, without distinguishing between different types.

But it's in very rare places that CNMs are allowed to attend births at home or in free standing birth centers

This is one of the reasons that I think home births are currently more dangerous than hospital births. Many home birth midwives are not trained to recognize and respond to emergencies when they arise. If home births were all attended by people with medical training, they would be much, much safer.posted by lexicakes at 3:01 PM on February 15, 2010

And I'll just say one more thing before I go--a lot of the things that are standard with hospital births, like laying on your back like a stranded fish (the worst possible position to push in) while "lots of people" look at your privates, hooked up to wires, in agony and fear...the movement towards midwives is part of the response to that.

If women are allowed to move, eat, drink, use natural pain relievers like birth tubs and massage, make noise if they need to, and have privacy and quiet around them, birth need not be the humiliating torture so many women experience. It may still contain pain, but it need not be agonizing or chaotic.

Here in NYC, some of the "best" hospitals have c-section rates between 40% and 50%.

One of the things that makes public reporting on hospital performance very, very difficult is the probability that the "best" hospitals are ending up with the most complicated patients--and those patients are the ones that are most likely to suffer bad outcomes. If you're talking about an intervention that has pretty much been disproven as an effective treatment for anything (IANAOBGYN but I think episiotomies may fall into this category?) then it's not necessary to correct for it, but it is probably a significant factor in the variation between hospitals for something like the cesarean rate. On a national level it makes sense for WHO to say that a c-section rate of 15% should be the target, but on a hospital level it may not make a lot of sense. The way the system really should be working is that little community hospitals have very, very low rates because they're referring all the high-risk pregnancies to big teaching hospitals with advanced NICUs (and from a hospital efficiency standpoint, you'd want that big teaching hospital with all the expensive specialists and equipment to be treating very few low-risk pregnancies, resulting in a higher c-section rate for the hospital).

It's hard to disentangle exactly how much of the variation between hospitals can be attributed to the relative complexity of their patient population (hospitals are always going to claim that it's 100% on any measure they perform poorly on) and how much can be attributed to the culture of the hospital and its admitting physicians (less than 100% but I suspect not as low as hospitals claim). Controlling for patient complexity in your performance measures is incredibly difficult but adds a lot of value from a consumer-information standpoint--in fact, not controlling for it can lead to data that is so misleading it's worse than no information at all--so I hope that is something that CIMS takes on in their quest for more transparent reporting.posted by iminurmefi at 3:12 PM on February 15, 2010 [4 favorites]

I loved being pregnant and like gaspode maybe two of these--specifically the fatigue and the aching feet--are all that applied to my pregnancy.

Hear hear birth survey. I've always felt like the real patriarchy in the birth process isn't most destructively expressed in (comparatively) minor ways like the use of stirrups or pressure to enter the hospital -- the worst part about the way we ignore women's experience is that we don't carefully and rigorously study reproductive systems and the reproductive experience. So this is long, long overdue, and hopefully will inspire a wave of research that will give people some data with which to work from.

Maybe this whole deal will get super trendy, and now someone will finally fund a big, comprehensive, double-blinded study on the relationships between different forms of hormonal birth control and depression.posted by Valet at 3:22 PM on February 15, 2010 [1 favorite]

iminurmefi, as Amy Romano pointed out on theblog of Beth Israel's Deaconess Medical Center's CEO, studies do not bear out that treating higher risk patients means that the c-section rate at the hospital is acceptable. Even when adjusted for high risk patients, the studies are still showing the rates to be too high.

Sure, I would expect a hospital with a Level III Nicu would likely have a higher than average c-section rate as often babies are born by c-section due to legitimate concerns and risks. But I would also expect the hospital with no NICU who would likely not take on super high risk patients would have a c-section rate that is significantly lower. But routinely this is not the case at all.posted by zizzle at 3:22 PM on February 15, 2010

Finished! That was an awesome survey - I love when I don't have to answer 'not applicable' to a whole mess of questions because the future questions are not linked to past answers.

Personally, I had a great hospital experience when I sure as heck wasn't planning one. I wanted to give birth at the hospital's free-standing birth center, but my 34-week old baby had other ideas. I hadn't visited the hospital's maternity ward yet, nor had I taken a childbirth class, but my midwife and the hospital staff were great about making me feel comfortable and explaining everything in detail. (I'm glad the survey also asked about NICU staff, since our baby was there for a bit. The NICU nurses rocked!)posted by Never teh Bride at 3:23 PM on February 15, 2010

I am so thankful I had a c-section, and was in a hospital. I wish the doctor had sectioned sooner, and that my unbearably rude labor nurse stopped pressuring me to push and have a "natural" delivery. My child and I would have both died that day if we weren't in a hospital, didn't have the secion. I think the pressure that women face to have home births, to eschew medical care, and to have natural births are irresponsible and dangerous. In the effort of Dr. Sears and other nutjobs to pressure me to have such a birth, I was woefully unprepared for the level of pain and reality of childbirth. Had accurate, real information been provided, I would have been much more able to prepare adequately, whatever method of childbirth I choose.

To be clear, I think those who want to give birth in the woods alone and clean themselves with leaves afterwards while eating the placenta or whatever is now trendy in childbirth should absolutely be permitted to do so. What I object to (but am not shocked by) is the misinformation and pressure placed on other women to adhere to this view as well. In the name of "women should be able to make decisions about their own birth" (a perfectly laudable goal with which I agree) we have women being just as or more so pressured toward homebirths and other methods as toward over-medicalization. I got that pressure, and am so thankful I ignored it.

I hope more unbiased information about womens' experiences is the result of this, to bring real experiences to the table and stop embarrassing women out of using professional medical care if they choose to.posted by bunnycup at 3:28 PM on February 15, 2010 [12 favorites]

bunnycup: I completely agree. I am also very grateful for my C-section, as my son could have been severely injured without it. I also got plenty of misinformation from the "natural childbirth" that left me unprepared for the reality of childbirth.

As far as C-section rates go, I'd really like to see a breakdown by necessity. I've heard all the stories of women who schedule C-sections for convenience, but I doubt that makes up the bulk of C-sections. I'd like to see stats showing which C-sections were emergency, which were medically necessary in retrospect, and which may not have been necessary, but seemed necessary at the time. The most interesting, I think, would be the C-sections which were not necessary in retrospect, but seemed so at the time. It would maybe point us to more information about determining when a C-section is necessary.posted by lexicakes at 3:40 PM on February 15, 2010 [2 favorites]

Who was on NPR the other day explaining that "women today" are really well-informed about their birthing options and, predictably, really polarized about "the best option"?

Anyway, seconding this from Valet:

the worst part about the way we ignore women's experience is that we don't carefully and rigorously study reproductive systems and the reproductive experience

I just completed the survey. WOW, I found some of the questions regarding c-sections and breastfeeding to be loaded, patronizing and biased.posted by bunnycup at 4:08 PM on February 15, 2010

Bunnycup, what about it? I'm sure the people who put it together would like to hear any feedback about it. There is an e-mail address you can send those comments to.

To me the questions just struck me as typical survey questions. "Did you want to breastfeed?" "Were you given support?" "By whom?" "Did you seek out support?" Those didn't strike me as patronizing but just information gathering.

Same with the c-section questions.posted by zizzle at 4:25 PM on February 15, 2010

I did send in feedback about it, in very strong words, with specific examples and wording copied and pasted. Unfortunately I no longer have access to the exact question text for examples, but here are a few thoughts I specifically remember.

Some of the questions about birth plans/c-section struck me as patronizing and biased. I had a birthplan in advance, and my practitioners (standard, medical doctors) were perfectly amenable to following it. However, I changed my mind as soon as I was in labor - because, in my opinion, the natural birth people misled me about the levels of pain and my expectations were laughably flawed as a result. Secondly, an emergency took place which further necessitated a change of plan. I felt the questions were biased insofar as the options assumed either my birthplan was followed (regardless of whether it reflected my actual wishes on the day of labor) or, if it was not followed, it was because the medical practitioners interfered with my wishes. I am not expressing this well. When I wanted to answer that my birthplan was not followed, the strong assumption was that it resulted from those jerky doctors not following my wishes. In fact, my wishes differed from the birthplan and then, an emergency c-section supeceded the birthplan. In all aspects dealing with my surgery and recovery, I felt an undercurrent assumption that I was not on board with the c-section or, at least, shouldn't have been. That it was imposed on me. A common misconception and area of pressure and misinformation.

With respect to breastfeeding, after I answered that I had wanted to breastfeed, there was no ability to explain that I wanted to but physically could not (because I was hemorrhaging, tachycardic, in surgery for a hysterectomy, in the ICU, receiving blood transfusions, on painkillers, etc). Thus, the questions assumed that hospital staff, not my partner and I, gave my daughter formula as necessary to sustain her life. Further, there was not adequate ability to answer that the child could not be with me because I was unconscious from bleeding, and the child was doing skin time, being fed by, and bonding with my partner. I found the entire set to underestimate the role of my partner - it allowed me to answer that he was there, but otherwise marginalized his role. Also, when it asked about how much information I was given about breastfeeding, the options were "None," "Not Enough" and "Just right" (paraphrased). For me, I was bullied about breastfeeding. I want the "breast nazis" as many women I know call them, to know to stop pressuring women. I want those studying childbirth to know that was the most negative part of my experience - worse than the near death and hysterectomy. I could not physically breastfeed, but these women would not leave me alone. Yet, the survey implicitly did not accept these views. All information was good information, no possibility for there to have been pressure. In my view, that reflects an assumption that we all can, want to and should breastfeed if only someone would bother us about it enough.

Now, please understand, I recognize that the things that happened in my labor and delivery were ridiculously uncommon. But what good is a survey that gives information on only the average, normal experience. Not every woman has a "normal" experience, and those of us who don't are already sidelined enough. I think the abnormal experiences are as important to understand as the common ones. I realize it's hard to create a survey that includes all options, but the question wording and underlying assumptions were a little restrictive, and made me uncomfortable.posted by bunnycup at 5:20 PM on February 15, 2010 [3 favorites]

For me, I was bullied about breastfeeding. I want the "breast nazis" as many women I know call them, to know to stop pressuring women. I want those studying childbirth to know that was the most negative part of my experience

I had the same experience with the breast nazis, and am behind you 100% on that sentiment.posted by misha at 5:35 PM on February 15, 2010

. . . I'm not doing this. I just don't have it in me. Forget it.

One order of twilight sleep for me, please!

Dan Savage once printed a letter from a man who watched his wife give birth, and was thenceforth unable to feel sexually attracted to her because her body had become so repulsive to him. No way I'm having a man in there who doesn't have a degree and a good chance of never seeing me again in my life.

I'm flip because I haven't yet been put in the position of considering whether or not to have kids, and I admit that. Still, I'm saddened by the industry of pressure not to be a Bad Mom before you're even a mother. Until about 1870 at the earliest, a woman who didn't have an "average, normal experience" in childbirth was a dead woman. (In fact, in some unfortunate circumstances that was the average.) It bewildered me -- in a totally sympathetic way, I should add -- to read a recent AskMefi question in which a woman felt bad that she needed medical help for her and her baby to survive the birth. I've seen too many rows of 18th century tombstones for that.posted by Countess Elena at 5:36 PM on February 15, 2010 [1 favorite]

I also took the survey, and I see bunnycup's point about the bias. What stuck out for me was that it asked if I had been pressured to have any of the interventions I had (Pitocin, epidural, or C-section), but never asked If I'd been pressured to breastfeed, or pressured to have a "drug-free" birth. Instead, it asked if I wanted those things. It seems to be implied that women choose to have a "natural" childbirth, but are pressured to have pain relief.posted by lexicakes at 5:37 PM on February 15, 2010 [7 favorites]

Well said lexicakes, you communicated that much more clearly than I was able to. Thank you.posted by bunnycup at 5:41 PM on February 15, 2010

What pregnant women won't tell you ever.

I'm not sure what pregnant women that blogger was hanging out with, but I've heard most if not all of those things and I've only picked up pregnancy information from reading books over my wife's shoulder and osmosis.posted by drezdn at 6:32 PM on February 15, 2010

Here in NYC, some of the "best" hospitals have c-section rates between 40% and 50%.

Here in NYC, we have some pretty seriously empowered, brilliant women who feel that we can make medical choices on our own, thank you very much and many of us like modern medicine just fine! The reputation is that if you want high-tech, go to Cornell; if you want earthy-crunchy, go to St. Lukes/Roosevelt.

Cornell will also probably see many of the IVF babies since they have one of the best fertility clinics in the world.

Anyway, my point is simply that if women are going to choose-- and it should be up to us!!!--- some may actually prefer c-sections and if they are making an informed choice (recognizing that it is major abdominal surgery and could potentially interfere with breast-feeding), it's not necessarily that these are unneccessary and the result of pushy lawsuit-fearing doctors.

Too posh to push is the patronizing way of putting it-- but if men gave birth, I imagine the debate would be quite different.posted by Maias at 6:47 PM on February 15, 2010 [3 favorites]

Here in NYC, we have some pretty seriously empowered, brilliant women who feel that we can make medical choices on our own, thank you very much and many of us like modern medicine just fine!

Thank you! The "Mother-friendly childbirth initiative" on that site is so patronizing. They say that every woman should be able to "give birth as she wishes," then turn around and say they don't "promote the use of analgesic or anesthetic drugs not specifically required to correct a complication." So, clearly, every woman should have the opportunity to make her own decisions about the birth of her child, as long as they're decisions of which the CIMS approves. A woman who has been in early labor for 16 hours and requests Pitocin and an epidural couldn't possibly be making an informed choice!posted by lexicakes at 7:55 PM on February 15, 2010 [1 favorite]

Maias, all well and good, but is there any evidence that the high c-section rates in NYC hospitals are the product of an extra strong preference for c-sections by the population of women who become patients at those hospitals? I know plenty of empowered and brilliant women here (my wife included) and their preference skews overwhelmingly in favor of natural childbirth. After two kids, my view is that childbirth in the US is too often geared toward the convience of doctors rather than the comfort of women.posted by brain_drain at 8:10 PM on February 15, 2010 [1 favorite]

Wow. That What Pregnant Women Won't Tell You Ever link is some pretty cynical shit. There's a lot of truth in there, and it's good to seea source for information that many women normally won't hear of from their OB's or family members, but damn a lot of the content in their seems to be wrapped up in a bit of bitterness, resentment, and regret.

Mrs. Armoir is in month seven of gestating our first co-humanlette, and we've been fortunate to have taken a class taught by a licensed midwife who has done 150+ births. She's been frank and informative and has taught us tons about what to expect (w/r/t expectations we've brought with us as products of late-20th-century American culture), how to be realistic about the various things that'll be thrown our way, how to avoid inductions, etc. etc. and yes we talked about pooping and perineal tearing and all the other unpleasant/painful/ghastly/horrendously-discomforting things discussed there. But thank god this class was taught in a much more mature and empathetic way than the shit on that website.posted by armoir from antproof case at 8:39 PM on February 15, 2010 [1 favorite]

The goal of those pushing for better ("natural" is a loaded and rather useless word) childbirth is not to increase pain. There are no legions of pain-loving crazies (individuals possibly, but not any of the many many organizations who do this kind of advocacy work) who want to increase women's pain.

So I'm calling that strawman out right now.

Stated briefly, here is what most of the organizations dedicated to changing the current state of hospital practice are concerned about:

1. Current, hospital-mandated procedures, traditions, and practices that increase pain--such as denying women access to food, drink, movement, and non-drug forms of pain relief (ie, birth tubs, showers, massage, etc) are both cruel and not backed up by evidence that they are good practice. Cases in point--forcing women to birth flat on their backs, episiotomies, too-early inductions, overuse of Pitocin to increase contraction strength--all of these procedures increase pain and suffering for women in labor. Epidurals can numb that pain, but they again make it impossible for a woman's body to move in labor, increasing her risk of stalled labor, and of injuries from pushing--she is unable to feel where the baby is, unable to move her hips or use gravity to help deliver her child, unable to know when she is doing herself an injury by pushing too hard or too soon.

2. Such actions also add additional danger by making it much more likely that labor will stall and the woman will need a c-section. Maternal mortality and infant mortality are higher with an unnecesary c-section than with a vaginal birth. Again: this is about safety, not against it. Like all surgeries, c/section has complications as well, up to and including adhesions, nicked bowels, injury to the baby, infection, and death.

3. The old canard about women dying in childbirth 100 years ago ignores both the role better nutrition has played in reducing childbirth mortality (ie, no rickets deforming hips, fewer child brides or starved women giving birth) and the fact that compared to similarly developed nations, the US's maternal mortality has remained troublingly high. If our high tech hospitals are so awesome why aren't our rates going as low as you'd expect?

4. The March of Dimes has also begun to express concern that the pushing of earlier and earlier inductions by hospitals is contributing to overall prematurity, leading to more developmental and health problems for babies down the road.

Personally, I never met any "breast Nazis", but I did get lots and lots of free formula samples and had my child fed sugar water postpartum against my expressed wishes, and a night nurse yank my kid off the nipple so she could do my blood pressure at 2am. But you know, yeah, hippies want us all to birth in the woods, crazy, amirite??posted by emjaybee at 8:47 PM on February 15, 2010 [11 favorites]

I'm not sure anyone raised that "canard," if in fact it is a canard, which I'm not remotely convinced given my own experience of very-near maternal and fetal death in childbirth. I'm not sure your tone has given me any reason to doubt my distrust of the natural birth movement and the tone it takes to women who choose not to adhere, either.

I'm happy to share one of my experiences with the breast nazis. I shared above the extent of my birth problems. My milk did not come in as a result. My daughter was latching, sucking and was rated excellently, but my body did not produce colostrum for over a week. I remember poor Vivienne trying to eat, and in retrospect I desperately wish that in the first week of her life I had just fed the poor child formula and stopped hand-wringing and guiltily obsessing about breastfeeding. One night, as my child was crying and hungry, the lactation consultant on duty, who later admitted to me she hadn't known my circumstances (including having lost 7 units of blood), gave me a hard time about what a bad thing I was doing for my child by giving her formula. I could barely sit up, and barely move, was not producing milk, and lactation consultants lectured me about using breastfeeding positions I was not physically capable of entering into, due to my 2 surgeries and blood loss, before finally bringing the formula. They told me I must not supplement with more than 10cc's of formula. Given that my daughter was not receiving any breastmilk, because I was not yet producing it, that was not enough for her. After coming home, I spoke with my sisters, one of whom shared a similar but even more egregious story, of having the lactation consultants insist she feed formula only through tubes connected to drip near her nipples, after she had similar bleeding problems. After coming home, we also had a nurse visit the day after discharge, who was appalled at the poor advice given me by the lactation consultants. I will always remember that, with sadness and self-blame that I listened to them.

The natural birth movement, as highlighted in emjaybee's prior comment, needs to do some serious and deep self-introspection about the advice it gives, inasmuch as many women have complications due to varying factors, prefer the presence of physicians, and do not fit the low-risk, uncomplicated mold. In fact, I was rated as low risk - I would have qualified for an at-home birth. Scary. And pretending that women don't really have these experiences, that we make them up, that we are stupid for buying in for wanting medical assistance, that we don't know how to evaluate pain and make our own decisions, is not helping gain respect for the movement.

emjaybee, as I said, I don't care where you give birth. I'm not peer pressuring you to go to a hospital. So stop sending that pressure and judgment other womens' way - because I can tell from your comments you felt judged and didn't like it.posted by bunnycup at 9:09 PM on February 15, 2010 [4 favorites]

A father going on five days here. My wife is the low key type, who does her research methodically without worrying others. About two weeks before her due date she gave me a copy of The Birth Partner from our local library with a few post-it notes, specifically about pain management, labour process, and positions. Although I was aware of the choices she was making in advance, this is really when I realized that "the system" can have a nasty habit of making all the choices regardless of the mother's wishes.

In the end, a lot of things went according to plan, and a few things didn't, but I'm grateful for knowing where there might be pressure to "get things over with quickly" and how to deal with it.

To be fair though, and to give hope to others, our hospital put everything at our disposal (birth ball, showers, squatting pads, etc.) and there was very little pressure and a lot of support. I don't think my wife was on her back at all except for a brief period where we were trying out the roll bar. She didn't ask for an epidural, and nobody proffered one to her since she didn't seem to be in any extensive pain (but don't be fooled, birthing is painful). All of this without a midwife or doula, just a doctor who listened in the weeks leading up and a modern, professional staff.

BTW, the worst part that I saw which nobody tells you about is when the mother on all fours with the (female) doctor's hand up her twat to confirm the position of the child's head while the mother simultanously goes through contractions (doctor: "I want to feel how strong the contraction is"). That part was literally a bloody mess on par with the worst fisting movie you may have accidentally seen, and leaves little regard for dignity. Be sure to keep looking in her eyes and let her know she's doing a great job!posted by furtive at 9:19 PM on February 15, 2010

Another area of bias in the survey questions was that they ask you to rate your doctor on whether she let you make your own medical decisions, along with, like, whether she treated you respectfully. "Always," "Sometimes," "Never." I mean, fuck. I didn't want to make my own medical decisions, but there wasn't any response for that.

As lexicakes noted, had I been interested in giving birth without pain relief, there would have been space to note that. But there was nowhere to say that I wanted an epidural going in, only whether I asked for it myself or was "pressured" to have one.

I will be horrified if we ever get to the point where medical professionals expect a laboring woman's pain to go away as long as she's got a bathtub and an inflatable ball. My childbirth experiences were peaceful, calm, joyous ... once I got the epidural, and I no longer felt that horrible tremendous pain, and I could concentrate on the wonder of what was happening.posted by palliser at 9:21 PM on February 15, 2010 [1 favorite]

Epidurals can numb that pain, but they again make it impossible for a woman's body to move in labor, increasing her risk of stalled labor, and of injuries from pushing--she is unable to feel where the baby is, unable to move her hips or use gravity to help deliver her child, unable to know when she is doing herself an injury by pushing too hard or too soon.

This is epic bullshit.

I was completely able to move my body in labor -- completely able to feel where my baby was, completely able to move my hips and legs, completely able to know when I should push and completely able to push. Many women are, and to ensure that I would be one of them, I had Patient Controlled Epidural Anesthesia, which means I had a very low-dose dripped constantly, and then I could give myself more by pushing a button when I needed it. I controlled the dose to allow myself pain relief while still retaining strength and sensation.

I learned about PCEA not from my childbirth education class, which was a load of exactly the same outdated findings you've regurgitated here (like that epidurals stall labor, which has been debunked, but keep ridin' that horse you guys saddled in 1988 or whatever), but from the head of the anesthesiology department at the hospital, who held a one-hour class for birthing mothers that was informative and taught at a very high level, given that it was a general audience.

I had a wonderful experience with epidural anesthesia, and I'm so glad I didn't go in fearing it, as so many women do (yes, often due to natural-childbirth advocates), and find I needed it anyway. So glad I got it as soon as the pain got bad enough to overcome the natural reluctance to have someone stick something in your spine. It's a wonderful thing.posted by palliser at 9:37 PM on February 15, 2010 [3 favorites]

Palliser, it's not bullshit. It may have been bullshit for you, but for many women it's not.

The type of epidural you had is different from the type of epidural I had. The epidural I had prevented me from moving at all and feeling anything at all --- except when it failed during surgery. That sorta sucked completely.

But, anyway. The point of the survey is to make maternity care more transparent. I think if a woman wants to have an epidural, then so be it. But you know what? There are many other types of drug pain reliefs that are just never offered. I recently learned of one called an intraethcal morphine drip that is apparently quite safe and doesn't prevent the mother from moving or feeling anything. I would have preferred that or a walking epidural, but no one told me my options. They just gave me some cocktail of drugs ---- I don't even know what drugs were in it!

The question is one of informed consent, and women are not being fully informed about all of their choices in childbirth. For example, I wasn't told prior to my c-section that I would face nerve damage that would cause me pain for 11 months. Yeah. 11 months of daily pain because of nerve damage. It took getting a second opinion, who after some trial and error determined seeing someone more specialized in the area of pelvic and abdominal pain might have some more insights. So I got a third opinion. I also wasn't told that in addition to pregnancy weakening abdominal muscles that the c-section would contribute even more to that that 14 months later, my stomach muscles are still nearly just as weak as they were in the post-partum period despite yoga and sit ups and crunches and other core exercises.

I also wasn't told anything at all about the 15% failure rate epidurals come with and the possibility that I might spend most of the c-section screaming. I wasn't told that many women are diagnosed as having PPD after birth and treated for it without results because what they really have is PTSD but no one talks about childbirth as being traumatic.

I agree that there seems to be great polarization between women who prefer medicalized births and women who would prefer natural births, but the primary concern CIMs has is making sure that women are treated with respect and are made a part of their medical care. It's about having real choice without fear. There were plenty of more things that I could have tried before having had a c-section, but no one mentioned them as possibilities. So while I consented to a surgery I didn't want, I'm kinda pissed that things like turning off the epidural, laboring down for a bit longer before pushing, or hell --- even being given the chance to push in the position I had wanted to push in would have made my consent far more informed. Had I been told about these other options and then had a c-section, I might have felt a little more at piece with the decision. As it is, I have a terribly painful experience and a lot of rage and bitterness at the way I was treated by the nursing staff and my doctor.

I don't feel that things were explained to me properly, and my birthing options for the future are absurdly limited. My right to choose the birth I want is not allowed in over 50% of hospitals in Massachusetts. If I were to become pregnant tomorrow and were to walk into a doctor's office or even a midwife's office 8 weeks later in over half the hospitals in my state, I'd be signed up for a repeat c-section 26 weeks from then. Informed consent in making a decision between a repeat c-section or a VBAC is stripped from me. And if I say I don't want the repeat c-section, I will either be dropped from care or bullied into it because of arbitrary hospital policy. What happened to my right to refuse treatment?

The goal of CIMs and the goal of the Birth Survey is really to make it clear that woman have the right to the birth of their choosing, and while I certainly stiffen and immensely dislike that women choose elective c-sections for their first birth experience, I don't feel it's my place to necessarily judge that. But I also don't think that just because I did have a c-section that my choice in a vaginal birth should I ever have another child (and after my last experience, I really don't think I will be because I just cannot bring myself to undergo another c-section) should be taken away from me. But for so many women in this country, it is. And that needs to stop.posted by zizzle at 4:22 AM on February 16, 2010 [1 favorite]

*not have been bullshit for you*posted by zizzle at 4:22 AM on February 16, 2010

zizzle, it is bullshit in the absolute way it was phrased -- that epidurals "make it impossible" to do these things. I said that for "many women," that wasn't true, and for women who have access to patient-controlled anesthesia, it shouldn't happen at all.

One of the things the anesthesiologist explained in the class is that everyone has a different sensitivity to anesthetics, generally distributed on a bell curve. Dosing is set to capture an amount of drug that will safely knock out pain for 95% of people. What that also means, though, is that you're effectively overdosing the majority of people (not in the dangerous sense, but just giving them more than they absolutely need), and thus potentially knocking out strength and all sensation, along with pain. That's what makes the patient-controlled epidural such a great advance, and one I wish more women knew about.

My problem with natural-childbirth advocates is that they don't talk about advances in anesthetics, and how to ask for them, and how safe they are, because their main goal is to get laboring women to refuse the demon pain relief. They let women walk into labor with unreasonable expectations of how painful it's going to be (note the 20th-century-expectations line above? heh, I know exaaaaaactly which Lamaze lecture that was), and utterly ignorant of something over 90% of them are about to do: get an epidural.

I think if a woman wants to have an epidural, then so be it. But you know what? There are many other types of drug pain reliefs that are just never offered. I recently learned of one called an intraethcal morphine drip that is apparently quite safe and doesn't prevent the mother from moving or feeling anything.

"So be it"? Okay then. Anyway, I have never understood preferring morphine in the bloodstream to local anesthetic in the spine. The former goes to the baby, along with anything else in your bloodstream; the latter pretty much stays, well, local. Yet my Lamaze instructor suggested starting with the morphine drip and working your way up to the epidural. Why do that when you don't have to -- when there's a more effective option that does a much better job of staying local to the mother? (Unless, of course, the mother is afraid of a needle in the spine -- very understandable -- and wants to try something else instead, in which case I fully support it.)posted by palliser at 5:54 AM on February 16, 2010 [1 favorite]

Oh, the other thing I forgot to address: I don't at all think I'm on either side of any "great polarization between women who prefer medicalized births and women who would prefer natural births," and I doubt there are all that many people who line up on either side. I think the extreme medicalized births of the mid-twentieth-century were horrible, and I wouldn't want that for myself at all.

I actually sought out a doctor with a low c-section rate (in fact, she's delivered 8 babies between my sister and myself, and only one of them -- one of my sister's -- was a c-section, due to fetal distress, and she's said my sister should have no problem delivering vaginally again in the future), and I do not at all consider myself to have had births with a lot of interventions. I got pain relief, yes. I also pushed the baby out with only coaching and catching, which I'm grateful to have had the choice to do. My point is that a lot of women would like a birth somewhere in the middle, if it's safe for them to do so.posted by palliser at 6:19 AM on February 16, 2010 [1 favorite]

I think the best thing a pregnant women can do is go in with an educated, yet open mind. You quickly find out that things never are text book and crap can go wrong at the most unusual, unexpected times.

I had a relatively great pregnancy. No risks, little bit of a lack of movement scares but overall, it was a very good pregnancy (cervix kicks and major foot/hooza swelling aside). Water broke at home, hardly any contractions, felt 3 and got my epidural stat. Slept, joked, enjoyed every moment. IV of pitcoin due to lazy contractions. Pushed. Husband was concerned about heart rate going down every time we pushed but no one said anything. You hear the doc say get the team ready. I thought it was normal to have a neonatal team.

Then we see crowning, pushing more and he shot out like a cannon. He was wisked away. Ok no big woop.

No crying. But I was still calm. I knew not all babies cry immediately. But then 5 min passed and you see that team say "suction" and hear all sorts of sucking sounds and "Apgar score 1" and then the freakout happened. When she said "sir turn the cameras off" my heart broke and I got angry. No f'in way was I going through all of this, finally bond, finally get a baby after infertility treatments to go home empty handed. This baby WILL go home alive with me, damn it.

Five minutes turned into 1/2 hour. I didn't see anything but a white, lifeless leg. No movement. No sounds. Just suction, oxygen rushing noises. It was horrible. A perfect pregnancy, pain-free labor, all was daisy sunshine then bam, this.

I never have felt so helpless, angry, and determined in all my life. Religion became my best friend. The nurses distracting me were going to get a punch from me. I want answers, not "oh look here, how are you doing?" I'm no doing fine, that's for sure.

After 30 min his Apgar shot to an 8. He was fine. I finally heard sounds--gurgling and grunting. They watched him a few moments more to see if he would continue to cry and filter that meconium out . Then they tell me not only did he have meconium in his lungs but his cord was around his neck, wrist, and leg. Should I have called the doc during my 2 trimester and the baby was going nuts in there? But this was way before my ultrasound, and surely they would have seen something then if it was bad.

I'm glad I went to the hospital I did. I dont' think our son would have made it at our local hospital (we went 40 min away from our house). I would have our 2nd child at the same hospital too. But it's not to say that that whole experience hasn't stuck with me a year later. It doesn't help he got severely sick with RSV at 6 weeks either. So twice I felt like I lost him and it still stays with me.

I think trust of your medical staff goes a long way. My friend was Miss Control Freak at the same hospital and had a horrid time. She fought every intervention possible and it didn't have to be an emotionally and physically painful experience. She was terrified and believed everything would go wrong and in the end, nothing went wrong until she interferred with labor progression (refusing pitocin when it was medically necessary). In the end, her kid came out fine and never got sick (knock on wood) but you would think she had the same experience I did.posted by stormpooper at 6:28 AM on February 16, 2010

Just finished the survey and found myself crying through most of it - I had managed to forget (or at least push down) a lot of the trauma - and the questions being asked did not adequately touch on my own situation. I also went in wanting pain modification, though I was hoping to push off having an epidural until I had experienced labor under Demerol or other less-intrusive meds... only to have no medical attention at all from the L&D nurses for the first 4 hours I was there - I spent most of my labor in the triage area, because there was no one available to check my progress or get me a room. I didn't even have my husband with me for the first 45 minutes, because they told him to wait in the waiting room, and then disappeared - he couldn't find anyone to tell him that it was okay to join me or where I was. By the time someone checked me, it was 'if you want an epidural, you have to have it now' - I was already at 6cm (9 cm by the time it took effect). So despite wanting pain relief, and having back labor on top of it all, I ended up experiencing 'natural' childbirth for most of my labor. And once the epidural did set in, I was so exhausted from the relief of it I was having a hard time pushing - which prompted the labor nurse - who it turned out was near the end of her shift - to tell me to take a nap. During active labor. I didn't know any better, so I did - only to be awoken by my furious OB wondering why I was sleeping instead of pushing (furious at the nurse, it turned out, and not at me, but at the time it was hard to tell the difference). My second L&D nurse was wonderful, but it was too late. I ended up needing forceps and a massive episiotomy to accommodate them, because I was unable to push effectively any more.

My baby was born healthy but a bit jaundiced, and ended up needing to spend an extra day in the bili-box after I was released - so even though I was still recovering from the episiotomy stiches and childbirth in general, I still had to haul myself to the hospital at 5 in the morning so I could be there to feed him when he woke up. I could have used another night in the hospital for my own recovery time; having to leave when my newborn was still there and needed me just tore at me emotionally - not to mention the added indignity of not having a room to recover in, and having to bring my little bag of toilet after-care supplies (squeeze bottles, pain-killer spray, gauze and sanitary pads) into the maternity ward's public bathroom stalls, since I was officially checked out and therefore completely able-bodied.

Mchelly that should have never had happened to you. Experiences like that deserve a letter to the CEO, labor and delivery director, doctor, and insurance company. I'm sorry you had an undeserving and painful labor.posted by stormpooper at 7:23 AM on February 16, 2010

My problem with natural-childbirth advocates is that they don't talk about advances in anesthetics, and how to ask for them, and how safe they are, because their main goal is to get laboring women to refuse the demon pain relief.

"Natural-childbirth advocates" are not a monolothic group whose members all say the same things and behave the same way.

To give another datapoint, my wife and I took a birthing class that was expressly intended for women who wanted to deliver vaginally and, if possible, without medications or other interventions. So the audience was composed 100% of people who were interested in this approach. Despite that, there was a whole session on epidurals -- what they are, the different kinds available, when to ask for one, etc. There was never the slightest bit of discouragement from getting an epidural. To the contrary, the attitude was, "you're here because you'd like to avoid an epidural, but some of you will change your mind when the pain gets bad -- and that's fine and normal, so here's what to do in that case." The midwives we worked with had the exact same attitude and approach. The overriding theme was that the comfort and safety of the woman are paramount.

I do agree that the survey questions here are not framed very well, and I can see how they would be off-putting.posted by brain_drain at 7:35 AM on February 16, 2010

(Zizzle) The goal of CIMs and the goal of the Birth Survey is really to make it clear that woman have the right to the birth of their choosing, and while I certainly stiffen and immensely dislike that women choose elective c-sections for their first birth experience, I don't feel it's my place to necessarily judge that.

I hesitate to say this because it veers off into something very patronizing very easily, but one of the concerns I have is that all the rhetoric in the world about choice of birth experience works for those who have uncomplicated L&D's. But when women are set up with the idea that we can and should choose our birth experience like we choose our shoes, our careers, our badass superpowers, etc., then it sets up unrealistic expectations. Those become dangerous expectations when complications happen, and a woman is fighting against medically necessary, appropriate or lifesaving measures because those measures are not the birth experience they wanted to have.

In my personal experience, the natural birth movement professes when criticized to be supporting nothing more than education and informed consent, but in reality the rhetoric is full of pressure, misinformation, and reduction of women's birth choices (or at least the ones other mothers will "allow" us to have without criticism).posted by bunnycup at 7:57 AM on February 16, 2010

Current, hospital-mandated procedures, traditions, and practices that increase pain--such as denying women access to food, drink, movement, and non-drug forms of pain relief (ie, birth tubs, showers, massage, etc) are both cruel and not backed up by evidence that they are good practice.

And not-so-current, yet still evil hospital-mandated procedures, which pretty much ensured yours truly to be an only child forever, namely: my mother going into labor on a Friday, laboring through the entire weekend and Monday day, not being allowed to eat anything but Jello (uh huh, that's going to keep you going for days on end), not being allowed to get up and walk around even though she very much wanted to, and finally, having a c-section Monday night that seemed to have been dreamt up by the dude from Saw (vertical cut, destroyed her abs forever...my god, I think the ob-gyn must've been drunk when he did the slicing)........ And this was the mid-1970s, not the 1870s. Fucking a.

Yes, I know the plural of anecdote is not data, but what my mother endured having me has forever colored me against using a hospital for giving birth unless they drag me in there, kicking and screaming. (And I kick really hard. They're gonna have to send extra EMTs... EMTs with tasers).

I swear, I'd rather give birth at my acupuncturist's office. She's an infertility specialist who's done rounds at the Cleveland Clinic, and I'd place bets she knows more about the female reproductive system than a lot of the people there do. Call me a hippie or whatever you want, I've seen her get results on a lot of medical problems the big fancy doctors have screwed the pooch on, so my skeptic radar about doctors knowing everything has skyrocketed since meeting her ten years ago.

(Also, anesthesia doesn't work so hot on me. I woke up on the table during elbow surgery. Good times).

If you want to be in a hospital, if you want to be on every drug in the book, good on you. Ditto if you want to breastfeed, don't want to breastfeed, want to feed the kid Mountain Dew the second it comes out. I don't care. All I want is to be allowed to choose how and where and with whom I go through that experience, and in many states, I would not be allowed that choice. That, I think, is wrong.

zizzle: Informed consent in making a decision between a repeat c-section or a VBAC is stripped from me. And if I say I don't want the repeat c-section, I will either be dropped from care or bullied into it because of arbitrary hospital policy. What happened to my right to refuse treatment?

It's the informed consent-stripping that I really hate the most. I'm educated. I am fully capable of researching and evaluating my personal risk in a given situation, especially with the help of competent and sympathetic medical professionals (my DO is awesome). It makes me sad someone like zizzle gets denied her right to make decisions because some hospital board is afraid of being sued (or whatever the basis for THEIR decisionmaking is, which seems in most cases these days to be "oh hell no, we're gonna get sued.").posted by bitter-girl.com at 8:21 AM on February 16, 2010 [1 favorite]

brain_drain, I suspect that my husband and I went to the same childbirth classes as you. Very supportive, wonderful experience. And completely comprehensive and balanced with regard to the pluses and minuses of medical interventions. My husband is a doctor (albeit a pathologist), and I work in a medical field, and both of us were impressed with the amount of (accurate!) information given.

Before I make a further comment, just to say, I had an easy pregnancy. I gave birth with no drugs. My labor went very quickly and uneventfully and, while tiring, it really wasn't very hard. The kid came out at 8lb 11oz, with a 99% head and an arm over her head. I had no tearing or stitches. I gave birth in a (NYC!) hospital, with an exceptional midwife. I am aware of how incredibly lucky I was to have such a good experience. Just so y'all know where I am coming from.

My number one problem with the vigorous natural birth advocates is that I believe they set you up from the outset for an adversarial relationship with your healthcare provider. I tended towards wanting as little intervention as possible (while being open to any and all) and as such, when I was newly pregnant, gravitated towards the more crunchy, pro-natural childbirth books to read. Maybe it's just me, but by the time I got through them, I was pretty much convinced that my midwife would strap me down, flat on my back, pump me full of pitocin and give me an episiotomy from my asshole to my bellybutton. OK, hyperbole, but seriously, the way they are written, and the way some of the comments here are written make it sound like there is no two-way relationship between you as a pregnant woman/couple and your provider. Plenty, plenty of OBs/midwives are open to many ways of giving birth. It's just... they have to, they must, prioritize your health and the baby's health above your experience. (My last job, I worked with obstetricians all day. We talked about this shit a lot, especially seeing as I was pregnant while working with them.)

I dunno. This is one of those very polarizing things. Problem is, unless they work in the field, most people have no more than their own experiences to work from, and to inform their opinions. Which is what? N's of 2 or 3 at most? I have an N of one. Maybe if I have another kid the whole thing will be horrible. But I'm assuming that if I didn't use the same midwife, then I would be able to find one (or an OB) equally as willing to work as a team with me. They are out there.posted by gaspode at 8:36 AM on February 16, 2010 [1 favorite]

Isn't the denial of food and water there in case there is an emergency requiring a general anesthesia C?

I don't know, maybe my husband and I are well informed and well, he's a big mouth when it comes to me and our son. But if I say "no" or question something and don't get an answer, shit hits the fan and no procedure is done until questions are answered and I'm comfortable with them. I know birth horror stories/experiences happen but I also wonder if it's a case of the patient being too afraid to speak or uneducated in their rights. My boss had a horrible birth experience because she didn't know that she could refused midwife student teaching during her birth. She experienced a lot of complications, stalled labor, and high forceps because the stupid midwives used her as a guinea pig--all because she said 'well no one told me I could say no to that consent form'.

Maybe it's also patient responsibility to say no, firmly and loudly, and know their rights and what should and shouldn't happen? Not blaming the patient but being loud, firm, and well have that tone of "want to fill out a malpractice suit" underlying helps in communicating to docs.

I thought I had a leak after my amnio. Receptionist 3xs when I called told me NO doctors were in the office (impossible) and to sit there even though I told her I could miscarry AT WORK AT MY DESK. I called my husband and he in turned called the office. He demanded that my doc or any doc get pulled from a patient room right now to answer the call. The docs were floored I was told such b.s. and apologized up and down. Again, it took me 3xs to call and I still sat there and you know, that was my fault for believing their b.s.. Some stupid receptionist combined with my shyness and doubting could have resulted in a miscarrage at my desk.

So speak up and speak loudly. We all have rights.posted by stormpooper at 9:06 AM on February 16, 2010

emjaybee: I think you misunderstand me. I didn't say that the goal was to increase pain. I was pointing out that their ostensible goals are transparency in maternity care, and making women more capable of giving informed consent. These are both really excellent goals, and they are things that should be addressed. However, it's very clear to me that the CIMS is biased in favor of certain practices, for example "not promoting" (which I read as "discouraging") the use of medications for pain relief. They also advocate for births to be attended by midwives (without mentioning what type of midwives). I don't have a problem with midwife-attended births. As I mentioned before, my labor was attended by CNMs and nurses. But that was my choice, and another woman may choose to have an OB attend her labor, and that's OK too.

My point is, stating "transparency" and "informed consent" as your goals is great. But in order for it to be truly informed consent, the information has to be unbiased.posted by lexicakes at 9:20 AM on February 16, 2010

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